Upload
lemien
View
221
Download
0
Embed Size (px)
Citation preview
Last updated September 30, 2015 for Spring 2016 intake Page 1 of 14
GREAT FALLS COLLEGE MSU
ASSOCIATE OF SCIENCE
NURSING (RN)
Student Information and Application Packet
Spring 2016
(Applications are subject to change year to year)
Last updated September 30, 2015 for Spring 2016 intake Page 2 of 14
Dear Prospective Associate of Science Nursing Student:
I am delighted that you are interested in the Great Falls College MSU Associate of Science Nursing Program. Nursing is a
profession that awards you a career for a lifetime. As a nurse for almost 30 years, I have found it to be a rewarding, exciting, yet
challenging career.
Registered nurses (RNs) work to promote good health and prevent illness. They educate patients and the public about various
medical conditions; treat patients and help in their rehabilitation; and provide advice and emotional support to patients' families.
RNs use considerable judgment in providing a wide variety of services.
Many registered nurses are general-duty nurses who focus on the overall care of patients. They administer medications under
the supervision of doctors and keep records of symptoms and progress. General-duty nurses also supervise licensed practical
nurses (LPNs), nursing aides, and orderlies.
RNs can specialize: (1) by work setting or type of treatment—critical-care nurses work in intensive care units, and psychiatric
nurses treat patients with mental health disorders; (2) by disease, ailment, or condition—HIV/AIDS nurses care for patients with
HIV infection and AIDS, and addictions nurses treat patients with substance abuse problems; (3) by organ or body system—
nephrology nurses care for patients with kidney disease, and respiratory nurses treat patients with disorders such as asthma; and
(4) by population—school nurses provide care for children and adolescents in school, while geriatric nurses provide care for the
elderly. RNs may also work in combined specialties, such as pediatric oncology (the care of children and adolescents with
cancer) or cardiac emergency (the care of patients with heart problems in emergency rooms).
According to the U.S. Department of Labor's Bureau of Labor Statistics, "Registered nurses are projected to create the second
largest number of new jobs among all occupations; job opportunities in most specialties and employment settings are expected
to be excellent, with some employers reporting difficulty in attracting and retaining enough RNs." Employment of registered
nurses is expected to grow much faster than the average for all occupations through 2018. In part, increases in demand are due
to technological advances in patient care, which permit a greater number of medical problems to be treated. In addition, the
number of elderly people is projected to grow rapidly, which should spur demand for RNs in nursing homes and long-term care
facilities. Employment in home health care is expected to increase the fastest; employment in hospitals is expected to increase
the least, largely because patients are being released earlier to reduce costs. Also, technological progress is making it possible to
bring complex treatments to patients' homes. Achieving RN status initiates the nursing career for many graduates; but may
represent the first step to an advanced nursing education for others. For example an Associate’s degree RN wishing to perform
multifaceted roles in professional nursing would progress on to the Baccalaureate level.
The goal of the program is to prepare the student for the NCLEX – RN licensing exam, which can be taken upon successful
completion of the course. Completion of the program does not guarantee eligibility to take the licensure exam and/or become
licensed.
The Great Falls College MSU has a limited enrollment capacity. Sixteen new students are enrolled in the Spring each year. The
small size is advantageous to our students, allowing more individualized attention and a greater amount of hands-on experience.
Due to clinical space competition and lab space, the small class size is a necessity. Limited enrollment can create a competitive
student selection process. It is important to review and understand our selection process. Please refer to the Application
Evaluation located in this information packet.
Information about the program and application materials for the spring entry is enclosed. Please read these materials carefully.
For additional information or answers to specific questions, please contact the Health Science Program Assistant at 771.4350 or
Kimberly Martin at 771.4356.
Thank you for your interest in the Associate of Science Registered Nurse Program.
Sincerely,
Kimberly Martin, MSN, RN
Program Director, Nursing Program
Last updated September 30, 2015 for Spring 2016 intake Page 3 of 14
Great Falls College MSU
Associate of Science in Nursing
Registered Nurse
Educational Program:
The Associate of Science Nursing program is approved by the Montana State Board of Nursing. The College is
also accredited by the Northwest Commission on Colleges and Universities. After prerequisite coursework is
completed, the Great Falls College MSU’s Registered Nurse program consists of two consecutive semesters.
The actual coursework for the Associate of Science Nursing program is competency-based and has the primary
goal to prepare graduates with the knowledge, skills, and values to enter the workforce.
Students commit to a full week at Great Falls College MSU each week. They are in class or at clinical for the
spring and summer semesters. This program, while very exciting, is extremely fast-paced and challenging.
There are many tests, quizzes, and assignments each week, to complete prior to class/clinical outside of class
time. The majority of students will find it necessary to spend outside classroom time as well as practicing
lab/clinical skills. A good rule of thumb is that for every class hour, at least 3 hours in preparation or in the
completion of assignments will be needed.
Program Expenses:
The Registered Nursing Students will be required to obtain an ATI computer program, personal equipment and
supplies, purchase uniforms, pay lab fees, and pay for transportation to field experience sites. If needed,
students should begin planning early for financial aid to meet their educational needs. Approximate program
costs can be found in the current catalog. http://catalog.gfcmsu.edu/academic-programs/registered-nurse/
Admission to the Great Falls College MSU
Students must be admitted to the College prior to the submission of the Associate of Science Nursing
Program Application and be in good academic standing with the institution. Therefore, no applications
will be reviewed unless the applicant applies first to the College and the official transcripts are reviewed
by the Registrar.
Acceptance to GFC MSU requires a completed admissions application file. An application to the college may
be obtained by visiting the campus, calling the College (406) 771-4300 or 1-800-446-2698, or applying online
at http://admissions.gfcmsu.edu/apply.html
Eligibility for Admission into the Associate of Science Nursing Program
All eligibility forms and documents are enclosed in the Associate of Science Nursing Program Information
and Application Packet for Spring 2016.
To be eligible to apply for admission into the Associates of Science Nursing Program, applicants must have the
following:
Show that they have been admitted to Great Falls College MSU, have a complete admissions file and are
currently in good academic standing.
A current unencumbered Montana LPN license.
Last updated September 30, 2015 for Spring 2016 intake Page 4 of 14
Completed all prerequisite course work and LPN courses with a “C” not “C-“grade or higher, a
minimum overall prerequisite GPA of 2.5. Prerequisite coursework can be taken at other institutions, but
it is the applicant’s responsibility to confirm those courses are equivalent to the ASN program’s
prerequisites and are transferable to this institution.
Information Regarding Transferable Courses – send official transcripts to GFC MSU Registrar’s
Office o Coursework taken at other educational institutions may be designated as equivalent courses
for Great Falls College MSU. For a current listing of approved equivalent courses, visit the
Transfer Guide under Student Information at:
https://atlas.montana.edu:9001/pls/gfagent/hwzkxfer.p_selstate
o If you have additional questions about transferability of courses, send a written request for
evaluation of your prior transcript to the Registrar at Great Falls College MSU. Please include
appropriate course descriptions and official transcripts from former colleges with your request
for evaluation.
Registrar’s Office
Great Falls College MSU
2100 16th Ave S
Great Falls, MT 59405
406-771-4312
o All transfer work has to be from a Regionally Accredited institution
ASN Transfer Policy
Any student who has failed two nursing courses will not be considered for admission. Any student who has withdrawn from any nursing course(s) more than once will not be
considered. Any transfer student must provide the Registrar Verification Form from their transferring
institution registrar indicating the student is in good academic standing (no suspensions or
probation) and is eligible to return to the institution (Form included in this packet). All students must meet admission requirements for Great Falls College MSU and submit
application for the ASN program; acceptance into the ASN program is competitive, application
does not guarantee acceptance. No course for transfer will be accepted unless a grade of “C” or better (not “C-“) was earned.
Program Admission Process
The Associate of Science Nursing Program Admissions Committee reviews application packets and uses
established admissions criteria to rank applicants for admission. The Application Evaluation form used by the
committee is enclosed. Criteria for selection emphasizes academic performance in PN course work, and
previous education, and medical work experience or Professionalism Rubric scores. All prerequisite courses
must be taken prior to submission of an application. Students must complete all of their prerequisite courses by
the deadline. All applicants must have a current, unencumbered LPN license with the state of Montana.
Equal Opportunity Policy Great Falls College Montana State University is committed to the provision of equal opportunity for education,
employment, and participation in all College programs and activities without regard to race, color, religion,
national origin, creed, service in the uniformed services (as defined in state and federal law), veteran status,
Last updated September 30, 2015 for Spring 2016 intake Page 5 of 14
gender, age, political ideas, marital or family status, physical or mental disability, genetic information, gender
identity, gender expression, or sexual orientation.
The College’s Equal Opportunity Officers are the Executive Director of Human Resources and the Assistant
Dean of Student Services, 2100 16th Avenue South, Great Falls, MT 59405. Telephone: 406-771-4300.
The deadline for applications to the Associate of Science Nursing Program is November 20, 2015.
Completed Program Application Packets may be hand delivered to Health Science Program Assistant at
the College or mailed to the College.
Contact Information
Health Science Program Assistant
Room R 227
406.771.4350 or
1.800.446.2698
Mailing address:
Registered Nurse Program Admissions Committee
Attention: Associates of Science Nursing Program Great Falls Montana State University
2100 16th Avenue South
Great Falls, MT 59405
Please send all application items as a completed packet. Items sent separately and at random are easily
lost or misfiled. We are not responsible for any late, lost or misfiled information.
Application Due Date: November 20, 2015. No late applications will be accepted.
Note: Submission of false material in this Application Packet will be grounds for non-admission
or, if discovered after admission, grounds for expulsion.
It is the applicant’s responsibility to ensure that all requirements are met by the established deadline.
Deadlines, guidelines, and policies apply equally to all students; thus, there can be no exceptions.
Great Falls College MSU’s Associate of Science Nursing Program does not maintain a waiting list.
Applicants must reapply each year.
Notification of Acceptance
Accepted students will be notified of their acceptance into the ASN program the week of December 25, 2015.
You will receive and must complete the intent to enroll form, and return it to the College. If this letter of intent
to enroll is not returned by the assigned. Accepted students will be required to provide proof of CPR
certification, negative Tuberculosis test, and immunizations, including flu shots, before the beginning of the
spring semester, at the nursing orientation. Students not accepted will be notified by the week of January 1,
2016.
Accepted students should plan on registering for any non-nursing courses in November and attending the
mandatory Associate of Science Nursing Orientation and Registration (date and time to be announced),
including a mandatory health science orientation.
Last updated September 30, 2015 for Spring 2016 intake Page 6 of 14
Health Sciences Division Policy: Student Back Ground Checks
To promote patient safety and decrease institutional liability, most clinical agencies require students to have cleared a background check and/or drug screening before they will permit the students in the clinical setting. To meet these requirements, the College requires that the check/screening be done prior to placement in any clinical agency.
Background checks/drug screenings are done at the student’s expense. Students with background checks that reveal a finding will be evaluated individually to determine whether they will be eligible for clinical placement and state licensure for their respective degree program.
Students are encouraged to go through Verifiedcredentials.com for their background check
Student Health Insurance Nursing program students entering the clinic setting must carry medical health insurance. Health insurance is
available through the college for students who do not have other health insurance. Students will be financially
responsible for their health care if they become ill or are injured in the clinical setting.
All GFC MSU students enrolled for 6 or more credits are required to have health insurance. For students
without coverage, GFC MSU offers a program developed especially for students by Blue Cross & Blue
Shield of Montana. This plan provides coverage for injuries and illnesses, on or off campus. Coverage
includes hospitalization, maternity, prescription drugs, surgical services, emergency room charges, and
immunizations among others. Please contact Student Central for more information.
Student Central
Great Falls College MSU
406-771-4414
Application Scoring:
Only students in Good Academic Standing will be eligible for program acceptance.
For applicants, who have taken courses multiple times; the most recent verifiable grade will be used for
scoring /GPA calculations.
Points and GPAs will be calculated by the Registrar’s Office and grade points will be calculated using the
current catalog criteria which includes +/- weighing. Plus or minus is equivalent to the following:
(A) = 4 (B-) = 2.7
(A-) = 3.7 (C+) = 2.3
(B+) = 3.3 (C ) = 2
(B) = 3
For students, who have been awarded credit for successful performance in subject examinations of the
CLEP or DSST programs, the credits will be accepted, however there is no grade for calculation for scoring
or GPA. In this situation, the total points will convert to percentages for ranking.
For students, who have been awarded credit for successful performance in subject examinations of the AP
program, the credits will be accepted for scores of 3, 4 or 5, however there is no grade for calculation for
scoring or GPA. In this situation, the total points will convert to percentages for ranking.
For students, who have been awarded credit for Experiential Learning, the credits will be accepted for
Passing (P) grades, however there is no grade for calculation for scoring or GPA. In this situation, the total
points will convert to percentages for ranking.
For students, who have additional educational attainment, the Registrar’s Office will verify degrees awarded
from official transcripts.
Last updated September 30, 2015 for Spring 2016 intake Page 7 of 14
Associate of Nursing Curriculum
Prerequisite Coursework
The following courses must be completed with a “C” or higher (not a “C-“) prior to admission into the
Associate of Science Nursing Program. Grades in prerequisite courses are a major factor in ranking applications
for admissions.
Course Number Course Title Credits
BIOH 201 Anatomy & Physiology I/ Lab 4
CHMY 121 Introduction to General Chemistry/Lab 4
M 121 College Algebra 3
NRSG 100 Introduction to Nursing 1
(semester I)
Total
12
Course Number Course Title Credits
BIOH 211 Anatomy & Physiology II/ Lab 4
WRIT 101 College Writing I 3
NUTR 121 Clinical Human Nutrition 2
PSYX 100 Introduction to Psychology 3
(semester II) Total
12
For LPNs with an active unencumbered Montana license, there is no age limit on the prerequisite credits.
Prerequisite LPN Coursework
The courses listed below are required in the program of study for the Associate of Applied Science in Practical Nursing.
The courses are offered at Great Falls College MSU in the following sequence:
Course Number Course Title Credits
NRSG 135 Nursing Pharmacology 3
NRSG 130 Fundamentals of Nursing 7
NRSG 138 Gerontology for Nursing 2
Total 12
Course Number Course Title Credits
NRSG 140 Core Concepts of Adult Nursing 7
NRSG 144 Core Concepts of Mental Health 2
NRSG 142 Core Concepts of Maternal / Child 3
NRSG 148 Leadership Issues 2
Total 12
Completion of LPN to RN Transition Course
NRSG 250 LPN to RN Transition 3
Last updated September 30, 2015 for Spring 2016 intake Page 8 of 14
ASN Program Coursework
The courses listed below are required in the Associate of Science Nursing program.
After acceptance in RN program:
SPRING SEMESTER
Course Number Course Title Credits
NRSG 250 Transition to Registered Nurse 3
NRSG 252 Complex Care Needs – Maternal/Child Client 3
NRSG 254 Complex Care Needs – Mental Health Client 2
NRSG 256 Pathophysiology 3
*BIOM 250 Microbiology ______4
15
SUMMER SEMESTER
Course Number Course Title Credits
*SOCI 101 Introduction to Sociology 3
NRSG 262 Complex Care Needs – Adult Client 4
NRSG 265 Advanced Clinical Skills 1
NRSG 266 Managing Client Care ______4
12
Once enrolled in nursing courses, a minimum of a grade of “C” in all courses is required to continue in the
program. In the clinical setting, students must achieve a grade of 75% in all rotations of each clinical
experience in order to continue in the program.
*Students are encouraged to complete these non-nursing courses prior to being accepted into the ASN program.
Last updated September 30, 2015 for Spring 2016 intake Page 9 of 14
NAME _______________________________________________________________________
ADDRESS ___________________________________________________________________
CITY _____________________________________ ST _________ Zip Code _____________
TELEPHONE (Home) _______________________ (Other) ___________________________
E-Mail ADDRESS ________________________________________________
STUDENT IDENTIFICATION NUMBER: _______________________________________
CURRENT MONTANA LPN LICENSE # _____________________________
Check-off List
√ Item
Completed Admissions File. A completed admissions file includes a completed application,
payment of the $30 application fee (if applicable), copies of high school/GED/HiSET transcripts
or diplomas, proof of MMR shots, and completion of placement testing or submit official
college transcript(s) verifying placement. Complete admissions files will be verified by the
registrar’s office and applicants with incomplete files will not be admitted to the program.
Students are encouraged to check with the admissions office to confirm that their admissions file
is complete.
In Good Academic Standing All students must be in good academic standing which means
they are not on academic probation OR academic probation continued, OR academic suspension.
Good academic standing will be verified by the registrar and any applicants who are not in good
academic standing will not be admitted to the program. Students are encouraged to check with
the registrar’s or admissions office to confirm that they are in good academic.
Application Evaluation (complete form for submission)
Technical Standards Form (signed)
Transfer students: Registrar Verification Form (completed by Registrar, in sealed envelope
and attached)
Verification of LPN work experience (form attached)
Official Transcripts for all completed secondary education
(Send transcripts to Registrar – no need to include in packet)
Copy of current unencumbered Montana LPN license
Please only send required documentation as other supplemental items will be discarded.
GREAT FALLS MSU
ASSOCIATE OF SCIENCE NURSING PROGRAM
Application Packet Cover Sheet
Last updated September 30, 2015 for Spring 2016 intake Page 10 of 14
Important Note:
The Montana Board of Nursing may not allow you to take the national exam following the completion of this
program. Acceptance for taking national exams, if you have a felony conviction, is approved or denied by the
Montana Board of Nursing on an individual basis. If you have a felony conviction, contact the Montana Board
of Nursing for further information before making an application to the program.
Nursing: http://bsd.dli.mt.gov/license/bsd_boards/nur_board/board_page.asp
Technical Standards Associate of Science Nursing Program --- Great Falls College MSU
To successfully complete the Associate of Science Nursing Program, students must demonstrate their
competency in carrying out tasks necessary for safe and effective practices in the field:
Perform entry data tasks using available technology
Provide all aspects of patient care including medication administration and treatments according to nursing
unit guidelines
Turn/reposition bedfast patient, alone or with assistance, to prevent hazard of immobility. Transfer patients
from bed to chair, bed to stretcher, chair to bed as needed throughout shift alone or with assistance
Transport patients in wheelchairs as necessary
Answer patient call lights or intercom system to determine patient needs
Perform CPR – ventilation/compression
Assemble medical equipment and supplies Maintain professional manner and decorum regardless of time pressures or frequent interruptions often
present in the clinical setting;
Maintain confidentiality with regard to all phases of work
Read, write, and accurately perform math calculations
Effectively communicate patient information in a culturally sensitive manner Accurately documents treatment information
Accurately differentiate colors
Respond appropriately to patients‘and other health care workers’ questions, requests, and directions
Accurately assess conditions of the human body
Demonstrate understanding and adherence to professional standards of nursing
The above listing is composed of general examples. Specific jobs may have other demands.
I understand that I will be expected to demonstrate competency in the technical standards stated above in order
to successfully complete the program.
Student Signature Date
Last updated September 30, 2015 for Spring 2016 intake Page 11 of 14
Application Scoring:
Only students in Good Academic Standing will be eligible for program acceptance.
Points and GPAs will be calculated by the Registrar’s Office and grade points will be calculated using the current
catalog criteria which includes +/- weighing.
For students, who have additional educational attainment, the Registrar’s Office will verify degrees awarded from
official transcripts.
All transfer work has to be from a Regionally Accredited institution
Please Complete
Applicant Name: Submission Date: _
Eligibility Assessment: (Place “Y” in blank to indicate requirement has been met)
Admitted to Great Falls College MSU, file complete and in good academic standing
Each Prerequisite course completed with minimum grade of “C” not “C-“ or higher
2.5 Cumulative Prerequisite GPA
A copy of current unencumbered Montana LPN license must be attached
Transfer students – Registrar Verification form must be completed, in sealed envelope
& attached
Prerequisite Course Work Record Please summarize your prerequisite course work by completing the table below and by sending official
transcripts directly to GFC MSU Registrar’s Office taken at another institution
Great Falls College MSU Course Course # Institution course was completed Credits Grade Term/Year Taken
Introduction to Psychology
Human Anatomy and
Physiology I with Lab
Human Anatomy and
Physiology II with Lab
Intro to General Chemistry with
Lab
College Writing
College Algebra
Clinical Human Nutrition
Introduction to Nursing
All non-LPN coursework completed with “C” or higher _________
GREAT FALLS COLLEGE MSU
ASSOCIATE OF SCIENCE
REGISTERED NURSE
PROGRAM Application Evaluation Form (3
pages)
Last updated September 30, 2015 for Spring 2016 intake Page 12 of 14
Admissions Criteria Score:
A. Performance in LPN courses (64 points possible): Grade A = 4, A- = 3.7, B+ = 3.3, etc. Multiply that number by the Emphasis = points)
Course # Course Title Grade Emphasis Points College taken
NRSG 130 Fundamentals of Nursing x 2 =
NRSG 135 Nursing Pharmacology x 2 =
NRSG 138 Gerontology for Nursing x 2 =
NRSG 140 Adult Nursing ___________ x 2 = _______________________
NRSG 142 Maternal Child Nursing ___________ x 2 = ________________________
NRSG 144 Mental Health ___________ x 2 = ________________________
NRSG 148 Leadership Issues __________ x 2 = ________________________
NRSG 250 LPN to RN Transition __________ x 2 = ________________________
Total first year nursing courses Score _________
B. Years ACTIVE in recent practice as LPN (10 points max) Verification required – see attached form
Years of Occupational Experience Points Total
<1 year 5
1-5 years 10
>5 years 5
Total for years’ experience Score _________
C. Previous Educational Attainment (5 points maximum –points awarded for one degree only)
Verification required –official transcript with degree posted on file with Registrar
Degree Attained Points Total
Master’s Degree 5 =
Bachelor’s Degree 4 =
Total Educational Attainment Score
D.. GFC MSU/MSUGF COT/Great Falls Vo Tech Nursing Graduate - Add 10 points
List date of Graduation:_______________ GFC MSU/M Nursing Graduate _________
TOTAL APPLICATION SCORE (total 89 points possible)
In case of a tie at the raw point level, these are the tie-breaking criteria:
Highest overall GPA Highest prerequisite GPA
“This training program is supported in part by a $15 million grant award from the U.S. Department of Labor. Because of this support,
veterans and eligible spouses may qualify for Veterans Priority of Service in this program. For more information, please contact Kim
Martin, nursing program director, 406.771.4356, [email protected].
This workforce program is supported in part by a $15 million grant awarded by the U.S. Department of Labor’s Employment and
Training Administration. The program does not necessarily reflect the official position of the U.S. Department of Labor. The U.S.
Department of Labor makes no guarantees, warranties, or assurances of any kind, express or implied, with respect to such information,
including any information on linked sites and including, but not limited to, accuracy of the information or its completeness, timeliness,
usefulness, adequacy, continued availability, or ownership. More information can be found at the following
link http://www.gfcmsu.edu/swammei/disclaimer.html. Unless otherwise noted, this work is licensed under a Creative Commons
Attribution 3.0 Unported License (http://creativecommons.org/licenses/by/3.0/us/).
Last updated September 30, 2015 for Spring 2016 intake Page 13 of 14
Great Falls College MSU
2100 16th Avenue South, Great Falls, Montana 59405
(406) 771-4300 or (800) 446-2698 Fax (406) 771-4329
REGISTRAR’S VERIFICATION FORM
FOR REGISTERED NURSE APPLICATION – TRANSFER PRACTICAL NURSE GRADUATES ONLY
.
This certifies that ______________________________________________________________________
First Name Last Name Other Last Name
Completed all coursework and clinical practice on: __________________________________________
DATE
Graduated on or is a candidate for graduation on: __________________________________________
DATE
Received the following degree: ___________________________________________________________
Name of Degree & Major Obtained
Is in Academic Good Standing at your College YES NO
From: _______________________________________________________________________________
Name of Academic Institution that granted the degree
Signed and the college seal affixed this _____________ day of __________________, _______________.
Month Year
I swear under penalty of perjury under the laws of the State of Montana that the foregoing is true and correct.
___________________________________________
Signature of Registrar
___________________________________________ [SEAL]
TYPE or PRINT your name and title
The GFC MSU Registered Nurse (RN) Application Committee must receive the
Registrar’s Verification Form with the application for the RN program in an officially
sealed school envelope sealed by the Registrar completing this form. This is to assure that
the Verification Form came from the school and was not opened by the applicant. Transfer
Practical Nurse Graduates submitting an application without a properly sealed Verification
Form will cause your application to be denied.
This form is to be completed in its entirety and signed by the College Registrar of the
school granting the LPN degree.
Last updated September 30, 2015 for Spring 2016 intake Page 14 of 14
ASN PROGRAM VERIFICATION OF
LPN WORK EXPERIENCE IN MEDICAL FIELD
Applicants may make copies of this form if they have been employed or volunteered at more than one site.
_____________________________________________________________ was employed as an LPN (PRINT) Last Name, First, Middle Initial
From _____________________ to ____________________ working an average of ____ hours per week. Month/Day/Year Month/Day/Year
Total hours of Occupational Experience: ______
COMMENTS/DESCRIPTION OF DUTIES: JOB TITLE ___________________________
____________________________________________________ _____________________________
Signature of Employer/Supervisor/HR Representative Date
______________________________________________________________________________
Name of Employer (Please Print)
______________________________________________________________________________
Mailing Address (Street Address, P.O Box)
______________________________________________________________________________
City, State, Zip Code
OFFICE USE ONLY
TYPE:___________________________ TIME: ______________________
REVIEWED BY:______________________ DATE: _____________________
GREAT FALLS COLLEGE MSU
Associate of Science in Nursing PROGRAM
2100 16th Avenue South
Great Falls, Montana 59405
406.771.4362 800.446.2698 ext. 4362